I staff the general hospital psychiatry consultation service. It’s a hit-and-run affair and I’m reflecting on how brutal it must seem to medical students and undergraduates who shadow. The residents are probably inured to it by the time they get to their second year. The Arnold P. Gold Foundation sent out a notice recently about what factors make medical students more interested in humanism in medicine. The notice cites a paper published in Academic Medicine in 2010 which clearly states that overwork and stress makes them less interested in humanism .
Psychiatry can be a stressful profession. Consultants in general hospitals sometimes don’t have time to…check that; I don’t take the time to debrief with medical students about death in hospitals and the difficult conversations I have with my colleagues in general medicine and surgery. I’m too busy thinking about the next patient I have to see that someone thinks is urgent and is not. I’ve become callous to death in the intensive care unit (ICU) where I’m called frequently. Sometimes I encounter patients still intubated, arterial lines and other attachments coming out of their frail and dying bodies–and finding out that death is imminent. It’s too late–and what was I expected to do anyway?
I rush on to where I’m paged, to the next crisis. Osler said that “callousness” is what physicians must cultivate . He also said that we must avoid “hardening the human heart by which we live” .
I think if there’s any way to make it more likely that medical students will choose psychiatry as their specialty, it should be teachers like me choosing to debrief the hard moments with them, one of them being the starkness and apparent inhumanity of death in the hospital.
And reflecting on this will show those who seek to regulate reflection and make it systematic by crafting empty, wasteful “activities” like Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) that they are not the ones who should lead.
We should lead the profession by adopting reflection on what we do and always seeking to evolve a few steps above the bitter landing where we stop to catch our breath. Why are we not leading this endeavor? Somehow we’ve lost the leadership role and let it be co-opted by managers.
We must show that we can lead in making a difference to our patients, to managers, to hospital credentialing committees, to medical students contemplating their professional futures, and to the regulatory boards who will stand down when we stand up.
1. Moyer, C. A., L. Arnold, et al. (2010). “What Factors Create a Humanistic Doctor? A Nationwide Survey of Fourth-Year Medical Students.” Academic Medicine 85(11): 1800-1807 1810.1097/ACM.1800b1013e3181f1526af.
Purpose: The authors sought to develop a conceptual framework of the factors that most influence medical students’ development of humanism and to explore students’ opinions regarding the role these factors play in developing or inhibiting humanism. : In 2006–2007, the authors conducted 16 focus groups with fourth-year students and first-year residents at four universities to design a conceptual framework. They used the framework to develop a survey, which they administered to fourth-year medical students at 20 U.S. medical schools in 2007–2008. : Data from 80 focus-group participants suggested that the key influences on students’ development of humanism were their authentic, unique, and participatory experiences before and during medical school, and the opportunity to process these experiences. Students who completed the survey (N = 1,170) reported that experiences of greatest intensity (e.g., being involved in a case where the patient dies), participatory learning experiences (e.g., volunteer work, international clinical rotations), and positive role models had the greatest effect on their development of humanism, whereas stressful conditions, such as a busy workload or being tired or postcall, inhibited their humanism. Women and students going into primary care placed significantly greater importance on experiences promoting humanism than did men and those not going into primary care. In addition, students with lower debt burdens viewed such experiences as more important than did those with higher debt burdens. Conclusions: Students viewed a variety of factors as influencing their development of humanism. This research provides a starting point for enhancing curricula to promote humanism.
2. Osler, W. (1904). Aequanimitas : with other addresses to medical students, nurses and practitioners of medicine. London, H. K. Lewis. Aequanimitas – The first essay